My mother is in a skilled nursing facility after a hospital stay. We are not that happy with the care. If she chooses to leave the facility before a doctor releases her, can she still get home health care through Medicare, if a doctor orders it? If she leaves skilled nursing, what are the ramifications as far as going back to the skilled nursing facility if home health care does not work out?

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GardenArtist: You're very welcome! Your advice is always spot on.
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I live with my elderly grandmother. And it’s just us for the past 3 years. So I have been taking care of her full time for like 2 years. After I started working, I was not able to be there for her all the time. That’s when I decided to hire a  24 hour home care in Toronto from C-Care ( 
For me, it was very helpful. The main thing was coverage. Even when I was not with grandma, she was never unattended, which gained me peace of mind.
The best thing about hiring a home care is that:
You can be sure that your loved ones are always around you and they are being looked after properly.
The nurses come to you on a regular basis and assist you with feeding, bathing, grooming and all the other needs.
The hours are flexible too.
Your loved one can maintain their dignity and independence.
Plus they will always feel safe with you around.
The residential care can be sometimes overwhelming for them.
Due to dietary restrictions of the residents, meals may be bland.
You may not be able to meet them, since the residential homes can be far away from home.
The home care I hired, also did a criminal background check on all their staffs. So it was pretty safe.
I felt safe leaving my grandma with the nurse.
Hope this could help you make up your mind.
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Dear answerplease; If your mom has an infection, and has been in bed for 3 weeks ,sounds like she Needs a nursing rehab facility ...Before you move her ,spend a few days at your mom's nursing home with her to see actually what has to be done for moms care...they maybe doing more than you think.NOBODY ever wants to be in a nurseing home rehab unit.and they are not pleasant because it's sad to be surrounded by sick people.If she doesn't have long to go maybe just let her stay or transfer to a different rehab unit close to home...It sounds like your mom is a sick lady please think hard before you make any rash decisions ...the nursing home staff is trained to deal with the infection and everything else that goes...GOOD LUCK 
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Llamalover, WOW! Thank you for such a kind comment. I'm really flattered!

Answerplease, some further thoughts after reading your updated response:

1. As already asked, about what are you specifically unhappy? If the issues haven't been discussed, you might want to consider asking for a sit-down meeting or at least a discussion, with the staff for those areas, with the idea that you'd like clarification and want to discuss some alternate approach(es).

I recently wrote about one of our experiences but can't remember the thread, so I'll just repeat myself! My mom had a broken leg, had a lot of pain and difficulty standing to walk after surgery. Because of that, the therapist determined she was"non cooperative". He was read to "call it quits."

We took Mom back to her ortho doctor who said she should be on nonweight bearing status on the broken leg for six weeks. He was very upset that the therapist was forcing her to try to stand on that leg.

In retrospect and through several rounds of therapy, I now see that the therapist was giving her exercises that shouldn't have been done for at least 2 - 3 weeks until her leg strength had returned. He was already pushing her to walk with the balance bars.

The proper approach would have been to sit on the therapy mattress and do nonweight bearing exercises first, while also strengthening her arms.

We asked for and got a family meeting with the staff - my father, sister (nurse) and me (formerly paralegal). Staff came prepared, ready to challenge, but my smart sister managed to turn the conversation away from criticism to "what can be done now, given the nonweight bearing limitation?"

The therapist suddenly was transferred to another facility. A very professional, congenial female therapist replaced him. All Mom's exercises for 6 weeks were nonweight bearing, and she made progress once the doubting therapist was out of the picture.

This might be an approach to consider, for whatever issues are of concern to you.

2. I agree with others; home therapy (especially with the former VNA) was very good. Nurses were outstanding. They liked my father and he liked them. They knew how to cajole, when to back off, when to move forward.

We also had another outstanding and very professional team through a local hospital out of Ann Arbor, which has a teaching hospital, high standards, trauma unit, and in our area is the place to go for serious health issues and higher level of care.

Dad progressed well with those therapists. And we've had good ones in his home area.

Not all are that great. You have to do your homework, and be available for the sessions so they know that you're involved. I've found that sometimes they slack off if the caregiver isn't there for sessions (not all, but at least a few, then show up randomly and spontaneously to let the home care team know you're still "in the picture").

3. Home care therapy can't by its nature be as thorough as in-facility therapy b/c the equipment just isn't available at home. Over several sessions, I've seen the value of "step-down" therapy: rehab to a given level in a facility, then home care to a higher level, then continuing at home with family encouragement to reach yet a higher level.

4. At one point we tried a private therapy facility, with very good staff and a variety of unique equipment adapted for elders' use. I'd never seen some of the techniques they used. They were definitely top notch.

But that meant that 3x weekly I had to take Dad out for therapy, and that was very challenging as winter became more intense. I was uncomfortable taking him out in such frigid weather, and made the decision that the only time I would do that again would NOT be in winter!

5. I think with your mother's condition now of being weak, not mobile, and bedridden, that I would try to stick it out at the rehab place, at least until she's walking. Trying to provide 24/7 care at home with someone who's still recovering from serious medical conditions would be too challenging for one person and just as importantly, for your mother.

If you did go home, it would be much harder on your mother and the therapy team to bring her to the level she needs to successfully move forward.

6. But absolutely address your concerns. If you want to be more specific, please do so here and I'm sure you'll get suggestions, especially if they are non PT but rather are medical issues.

And if you still feel the treatment is inadequate, go for the meeting approach and see what can be worked out.

7. I see rehab therapy in a facility as a precedent and absolutely necessary for home therapy; otherwise, home therapy can be much harder and progression more difficult. It's kind of a step-down issue.

I saw that last time my father was in rehab; the staff kept bugging me to transfer him to AL. He would never go and I was tired of them haranguing us on that issue.

(One of my excellent bosses told me he chose his battles carefully and didn't spend time on ones he couldn't win. That's the way I characterize the battle of my father staying at home for the rest of his life vs. going to an AL which would depress him and make his life miserable. I might "win the war" but I've lost the battle, and I know he would decline and eventually die with negative feelings toward me. I'd rather he go with positive feelings; it'll make the end easier for him.)

8. One of his friends and I also noticed that the therapy at the rehab facility was far from the standard when I first brought him there back in 2012. It was completely, totally outstanding then. This year, it was mediocre.

The therapists were always in a bad mood, rushed, not very tolerant, and at one point I thought almost retaliatory. So I was glad to take him home, but he had NOT been brought to the point of home care.

8. It was the worst transition I've ever seen. He wasn't prepared, was still weak, and it resulted in a depressing few weeks until he was able to make more progress. I actually didn't expect him to last through the summer.

But when I got a good home care team in, that made all the difference, and he slowly progressed.
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GardenArtist offers the correct answers, as always! Thank you, GardenArtist.
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Tough it out at rehab for awhile unless there's clear signs of something really bad going on there
With an infection, she has a long road to recovery
If she's bedridden, how will she be cared for 24/7 at home?
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To me it would depend on what therapies she's receiving at rehab and if that can be duplicated by home health. The experiences I've had with my mom's home health PT pales in comparison to the PT at rehab. While she's never been overly happy to be at rehab (multiple occasions!), I think "going home" is her motivator to do her exercises and listen to what the PTs and OTs tell her. Unfortunately, once she gets back to her assisted living and is back to 3 days (maybe) of PT a week, she immediately goes downhill. If you go the home health route and she doesn't *continue* to improve, Medicare will no longer cover payment for PT.
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The rehab facilities are much better than home therapies, per my experience.

We did find ONE pt home therapy that was very thorough, yet it is very rare to find such dedication.

I would have a meeting where she is now and provide concrete examples of what could improve for her there.
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I agree with Jeanne (again!) that tackling the problems you're having at this centre - which otherwise sounds pretty good, given how conscientious they're being about her rehab schedule - might be a better way forward; until you can get a formal plan in place, at least.

Also, who is unhappy, and with what? Are we talking about specific incidents or deficits in standards that you or other family members have noticed, or is it more that your mother is expressing that she hates it there and wants to go home, in a more generalised way?
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How severely are you "not happy with her care"? Is there something that could be improved with her care that would make you less unhappy? Do you want to take her directly home, or to a different rehab facility?
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Thank you for responding. My mother is in rehab because after two hospital stays for two different infections, she is very weak. She was not very mobile before the hospitalizations, but now she has been bedridden for almost three weeks. They are giving her PT and OT at the rehab facility. She would like to go home, but we don't know if the therapy provided by home health care will be enough to help her recover. She was getting PT through home healthcare before the hospitalizations, which was fine. But now we are concerned that she may leave rehab and discover that the therapy provided by home healthcare is not enough, and in that case, she would need to go back to rehab, which may be closed to her if she leaves rehab before being released.
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1. Yes, you can leave a facility before the responsible person (physician who treats at the facility) releases her, and go to another facility providing that your mother's "regular" (non nursing home) doctor provides a letter, indicating you want to transfer but still want rehab, just in case Medicare challenges the move.

We did this, with no problem at all. I did make sure to get a letter, but Medicare never challenged.

2. If she leaves and you indicate the reason is dissatisfaction, the facility admins and/or doctor might not be very happy, and might not be flexible in scripting for home health care. If one of her regular physicians scripts for home health care, you can get it and Medicare will pay.

Just to "hedge your bets", you could indicate that there are issues with Mom being away from home (traumatized, confused, etc.), you have trouble visiting her, or some legitimate sounding excuse.

3. If you leave the current facility, get home health care and it "does not work out", I rather doubt that the same facility you've left would be amenable to take you back. "No Medicare beds" would probably be the justification.

I sense there's a lot of uncertainty about what to do, including what will happen with home health care. Have you been through this sequence before with your mother? Why are you concerned that "home health care does not work out?"

I think that would be one of the issues to address first.

Why is your mother in a facility for rehab now?

It's also a good idea to do some thorough research on home health companies so that you select one in which you have confidence. Not all of them are that good.
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